Salad-Bar Medicine: You Choose Your Fate

ELLEN GOODMAN

Boston. -- Over the past winter, two women of a certain age brought their biological stories to their friendly neighborhood gynecologist for a mid-life checkup.

Each woman shared her symptoms -- who the hell is fooling around with the thermostat in this body? -- and her family history. Each received a thorough examination.

One of this duo left with a package of teeny-weeny hormone tablets, while the other did not. What made this surprising was that these women not only had the same complaints and the same doctor -- they had the same family history. They were sisters.

Of course, upon further conversation, the two figured out that in fact they had proffered fairly different versions of their medical heritage. They had picked independent anxieties off their common ancestral tree -- one emphasized cancer, the other did not.

But the notion that fairly minor discrepancies could steer a major decision one way or another is still enough to give either of them, uh, hot flashes.

I retell this family story now because another estrogen study has just been added to the menopausal pile. The New England Journal of Medicine reported Thursday on a 10-year study of 49,000 nurses. Their study indicates that women who take estrogen after menopause cut their risk of heart attack almost in half.

So we draw another daily feature onto the composite portrait of risks that is emerging like a most-wanted poster in the police station. Estrogen will probably cut the risk of heart attacks and osteoporosis. But it is believed to raise the risk of uterine cancer and may or may not raise the risk of cancer of the breast.

Add progesterone to the hormonal mix, and the risk of uterine cancer goes down. But nobody knows what that will mean for the breast or the heart beating within it.

Does this begin to sound like the salad bar approach to medicine. Which would you rather have, cancer or a heart attack? Broken bones or cancer of the uterus? Step right up and choose your fate. Don't bang your head on the sneeze guard.

These days, it isn't raging hormonal imbalance that drives a post-menopausal woman berserk. It's raging medical debate. Some 30 to 40 million American women are now searching for Dr. Right. They want a definitive answer on estrogen, and instead they're getting the daily odds.

The answer to this is of course more research. I belong to the cohort of women who believe that we will only get serious research on these subjects as the first critical mass of women doctors passes through the life cycle.

But research doesn't necessarily clarify things. It may just add new items to the salad bar.

In just the past months, for example, we found out that Finnish men who lowered their cholesterol, blood pressure and weight, were MORE likely to die of heart attacks than those who went about their bad old ways. We read that British men who drank booze in moderate quantities had a lower rate of heart attacks than those who drank totally tea.

What have we learned? Give up cheese here or move to Finland? Your liver or your heart? Is this true for the British goose as well as the gander? Dress this salad with confusion.

The estrogen research done with these nurses does try to assess the overall odds. Heart disease is a much greater killer of women -- yes, it is so -- than breast cancer. Anything that greatly lowers the chance of a heart attack is going to save lives, even if it slightly raises the chances of cancer. But that isn't an answer for one sweaty patient holding her own family's history in the waiting room.

Increasingly, medical research subdivides us by risk factors and background, by race, gender, ethnicity, lifestyle, diet and, of course, genes. We are moving into an era of information glut and decision-making gridlock. Medicine is increasingly individualized and diffuse. The uncertainties that characterize the debate about estrogen are becoming the norm.

The practice of salad-bar medicine means in essence that doctors who once told us what we should do, are more likely now to tell us what we can do. They lay out the options before us, rack up the risks. And there we are on our own, with an empty plate and shaky set of tongs.